Would you irradiate?

[BraggPeak]

48 yo female with t2 Invasive ductal of left breast, er/pr +, her2 negative. Patient had extensive associated DCIS and ultimately underwent a mastectomy with expander placement and SLN biopsy. Tumor was 2.1 cm, no LVSi, and all margins negative (3 mm anterior, all others 1.0 cm or more). She had 1.8 mm of disease in one SLN. No ECE. No axillary dissection.

Final stage: t2 n1 mic Mo

Med onc did oncotype and score was 12 so patient is getting endocrine therapy alone.

Would you irradiate?

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[medgator]

Grade?

 

[BraggPeak]

Grade 2

 

[medgator]

If she had had the completion dissection with negative findings, I might be inclined to not radiate, but extrapolating from Z0011, I am tempted to offer her treatment.

Were both the nodes negative on frozen?

Might be a different discussion in an older patient

 

[OTN]

I would go with a completion AXLND, and if no other LNs were found in the dissection I would not irradiate.

 

[Burt Radnolds]

How many sentinel nodes obtained? Either way you are in a tough spot here. In Z0011, 10% of patients with micromets identified on sentinal node had additional macromets on ALND. Micromets are still considered positive, and current standard of care would be further addressing the axilla, through dissection or RT, in my opinion. In truth however, the most appropriate course of action MIGHT be no further axillary therapy, but its a bit of a dice roll and only hindsight will be 20/20 here. It would be easier if there were more high risk features to push you in a direction, but instead you are left with a bunch of low risk features. Unfortunately this type of thing is becoming more and more common as surgeons shy away from dissecting the axilla, outside of the specific conditions that were met in the recent trials, leaving us to scratch our heads about what to do.

My conservative opinion is that the axilla has not been fully addressed, and that she needs further axillary therapy, based on current standard of care. However, given the plethora of lower risk features, this could be overkill and you might find some people willing to forgo dissection/radiation.

 

[BraggPeak]

The lymph nodes were negative on frozen. There were only 2 lymph nodes obtained....

The ki67 was only 15% (again borderline)!

 

[hot sauce]

I would irradiate. She is a young woman with N1 disease. I am aware of the limitations of the british columbia and dutch data on PMRT, particularly given her low burden of disease. However, these studies showed a large OS to PMRT in node positive women. The fact that she only has a small amount of the disease in the lymph node suggests that her benefit may be smaller but she also has a lower competing risk of distant failure. The fact that she is not getting any chemotherapy and only had a SLN makes the choice clear in my mind. In the future, we will hopefully have better data and may be able to spare women in this situation radiation but I would not forego PMRT in this patient based on what I suspect may be future standard of care.

 

[thaddeus]

MSK has a helpful nomogram for predicting risk of additional non-sentinel node positivity for patients who only had SLNB:

http://nomograms.mskcc.org/Breast/BreastAdditionalNonSLNMetastasesPage.aspx

Plugging in her data gives a risk of 10% of additional non-sentinel nodes, in agreement with the overall results from Z0011 quoted above.

Standard of care aside, offering adjuvant radiation for only a 10% risk of additional nodal disease seems a bit marginal to me (number needed to treat to prevent 1 recurrence = 20 if we assume we cut her risk of recurrence by 50%), but ultimately would have to be patent's decision based on her own risk/benefit calculus.

 

[medgator]

MSK has a helpful nomogram for predicting risk of additional non-sentinel node positivity for patients who only had SLNB:

http://nomograms.mskcc.org/Breast/BreastAdditionalNonSLNMetastasesPage.aspx

Plugging in her data gives a risk of 10% of additional non-sentinel nodes, in agreement with the overall results from Z0011 quoted above.

Standard of care aside, offering adjuvant radiation for only a 10% risk of additional nodal disease seems a bit marginal to me (number needed to treat to prevent 1 recurrence = 20 if we assume we cut her risk of recurrence by 50%), but ultimately would have to be patent's decision based on her own risk/benefit calculus.

Age imo is the tie breaker. I might be tempted to leave someone alone who is post menopausal, but not pre